If you have back or neck pain and you fail physical therapy or chiropractic care, you’re likely to see a doctor who specializes in interventional pain management. This is a medical specialty that largely uses steroid injections, diagnostic numbing injections, radiofrequency ablation, stimulators, and the like to help patients control pain.
How Behind Are Academic Pain Management Programs?
We often think of academic medical centers as cutting edge. In many ways that’s true, but not when it comes to image-guided injection treatment of the spine. Chris Centeno, MD, a specialist in regenerative medicine, gives his thoughts on this.
The first thing that the fellow (A fellow is a doctor who has completed medical school and residency training in a medical specialty and who wants to continue his or her education) candidate asked was what I was injecting inside a patient’s disc and why. In his fellowship program, all that ever gets injected inside someone’s disc is large amounts of radiographic contrast and steroid. I quipped that this was a great way to kill disc cells. Meaning that by injecting large amounts of contrast (the stuff that you can see on x-ray guidance or fluoroscopy), his attendings (the name for a senior doctor in a medical education program) were killing disc cells. We’ve known this since about 2012 (1,2). In addition, by injecting steroids into the disc, this was also killing the cells inside the disc (2).
So what did I do differently? I used a tiny amount of contrast to confirm that I was actually inside the disc (0.05 ml or less). This is the opposite of what he’s being taught because his attendings routinely inject 20-40 times more. I then didn’t inject high dose steroids into the disc, but platelet-rich plasma (PRP), which is concentrated platelets from the patient’s blood. This has been shown to help the disc cells survive (3,4). I also injected differently. While a traditional pain management doctor would want only to inject something inside the disc in a place called the nucleus pulposis, I spent quite a bit of time injecting both the right and left annulus fibrosis (the outer covering of the disc). Why? Because this patient’s MRI showed damage to that structure. Hence, the purpose of my injection was to achieve functional repair of the disc rather than to determine if it was causing pain (discography).
This doctor’s next question came when I was injecting the same patient’s epidural space. That means that I was injecting around irritated spinal nerves. His attendings would only ever inject long-acting anesthetics and high dose steroids into this space. I then told him that this again was a great way to hurt the nerve cells (5-9). So what did I do differently? I injected platelet lysate because it contains nerve growth factor and other elements which can help nerve cells (10-12).
RFA vs High-Dose PRP Injections
Another topic that came up was how interventional pain management doctors are much more interested in radiofrequency ablation (RFA) of the facet joints and I was injecting them with PRP. RFA is a procedure where the doctor uses electrical energy to burn the nerves that take the pain signals from the low back joints to the spinal cord and brain. The problem? That same nerve also supplies critical stabilizing muscles which then die off as well (13,14). This results in instability in the spine. So RFA helps one problem and creates another. Instead of killing critical nerves, my approach was to inject a high dose PRP into these damaged joints (15).
Another big observation that the fellow candidate made was the pace of what we were doing. In his current program, the pain management attendings are required to turn over 20-40 different patients a day. Basically, it’s assembly line, high-volume care. Each patient gets a one or two-level quick injection procedure and then is pushed out the door as quickly as possible. In contrast, I spent a full two hours on one patient performing many different injections in many different parts of the low back and neck.
After a few hours of discussion over my patient procedures, the fellow candidate finally concluded that the main salient difference between where he’s working now and our clinic was outcomes. Our focus is on how can we use the best stuff in the best way to give the patient the best chance of success. Regrettably, in his current fellowship, the data is clear that many procedures they perform don’t help patients in the long-run and some things clearly hurt patients. Meaning it’s more about checking the boxes than what’s best for the patient.
When Will Academic Centers Catch Up?
What was the most interesting was how behind the times academic centers still are in moving from destructive spine care to regenerative spine care. This is a hard one for most patients to understand, as they have the sense that the local, big-name academic medical center is at the cutting edge of research. While in many ways that’s true, not when it comes to regenerative spine injections.
Why is this case? These academic medical centers are also businesses. Without widespread insurance coverage for these newer approaches, they can’t pull the trigger and allow their doctors to widely adopt them. So in the meantime, they continue to treat spine patients like it’s 1999.
The upshot? Regenerative spine care is here to stay and destructive spine care needs to be shown the door. Having a fellow candidate around just serves to remind me of how far ahead regenerative medicine is when compared to what patients can access at their local university hospital. We await the day when the academic medical centers finally catch up!
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